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Vaginal Candidiasis and HIV Disease

January 2011

Vaginal Candidiasis and HIV Disease

Vaginal candidiasis is a fungal or yeast infection of the vulva and/or vagina. It causes a smelly, thick, white-yellow discharge that might be accompanied by itching, burning and swelling. It can also can make walking, urinating or sex very painful.

Vaginal candidiasis can be an occasional problem for even the healthiest woman. However, it's more common and severe in women with weakened immune systems. For many, a repeating or worsening vaginal yeast infection is the first symptom of HIV infection. This infection can occur at any CD4 count but is likely to occur more often when your CD4 count falls below 100.


Vaginal candidiasis is caused by the fungus called Candida. Everyone has small amounts of the fungus in the mouth, vagina, digestive tract and skin. In healthy persons, their immune systems prevent it from causing infection. However, a weakened immune system can allow the Candida to grow and cause disease.

Certain drugs can alter the natural organisms in the vagina, which can then allow the Candida to grow. These include the extended use of antibiotics, steroids and oral contraceptives (birth control) with a high estrogen content. Other factors that may cause candidiasis include diabetes, pregnancy, using antihistamines and iron, folate, vitamin B12 or zinc deficiency. Cancer chemotherapy, stress and depression can also contribute to the disease. Tight fitting pants and reactions to the chemicals in soaps and detergents can lead to vaginal candidiasis as well.



Vaginal candidiasis is usually diagnosed by appearance and symptoms. Because symptoms are similar to many other conditions, like the sexual infection trichomonas, your doctor should confirm a diagnosis by scraping the affected area for examination under a microscope.


Topical treatments (applied on the affected area) are the first choices for yeast infections and these generally work for mild-to-moderate cases. These include vaginal creams, suppositories or tablets. Many are available over the counter.

Most topical treatments last only a few days. Longer courses (7-14 days) may be more effective in HIV-positive women.

Generally, topical treatments do not cause side effects, but in a few women they may lead to vaginal burning, itching or skin rash, or even cramps or headaches. Oil-based vaginal creams may weaken latex condoms and diaphragms.

If topical treatment does not work, or if outbreaks recur often, you may need oral drugs. A single oral dose of Diflucan (fluconazole) is increasingly used to treat vaginal candidiasis.

Antifungal Drugs and Pregnancy

Antifungal Drugs and Pregnancy

The Federal Guidelines for the Prevention of Opportunistic Infections recommend not using antifungal drugs during pregnancy due to possible birth defects. They further state that azoles be stopped in women who become pregnant and that women taking these drugs use effective birth control.

Topical therapies may be preferable for pregnant women. For systemic treatment the Guidelines suggest using AmB, especially in the first trimester.

Although no formal studies have been done, pregnant women have used amphotericin B without apparent harm to their unborn children, though the drug has possible severe side effects including kidney toxicity and anemia.


Using antifungal drugs to prevent fungal infections is approached with great caution and is generally discouraged, especially using fluconazole this way. This makes treating newer and more aggressive infections more difficult and often unsuccessful. However, this may not be possible in some people with recurrent infections who must remain on long-term therapy to prevent them.

Some Final Thoughts

Candidiasis is among the most common conditions in people with HIV. It's often the first sign of HIV disease progression, particularly yeast infections that recur or respond less to treatment. Candidiasis outbreaks can be frequent, cause great discomfort and add to the decline in health seen in AIDS. Prevent and treating vaginal candidiasis will improve discomfort and reduce further damage it may cause to your immune system.

Other Publications That May Help

Oral Candidiasis

Systemic Candidiasis

Preventing Vaginal Candidiasis

There are many practical ways to try to prevent vaginal candidiasis. For women with recurrent disease, a single dose of fluconazole weekly is sometimes used to prevent the infection. Caution is recommended when considering this approach since its extended use of fluconazole can result in resistant candidiasis.

Practical Prevention Tips

  • Avoid douching. Douching changes the normal acid level in the vagina and causes inflammation, both of which may increase the risk of infection.
  • Try not to use scented laundry soap, bleach or fabric softeners. These products can cause yeast infections. Bleach may harm the friendly bacteria that stop Candida from taking over. Also, fabric softeners stop moisture from escaping, keeping the skin damp and more likely for yeast to grow.
  • Avoid tight clothes which block air flow.
  • Wear cotton underwear as it lets air in and moisture out.
  • Avoid washing with deodorant soaps or bubble baths. Non-soap cleansers are less likely to irritate the vaginal area.

Food as Prevention

  • Decrease or avoid sugars (corn and maple syrup, glucose, fructose and sucrose). Sugars are food for Candida and help it grow.
  • Decrease or avoid alcohol. Alcohol converts to sugar and helps Candida grow.
  • Swallow large amounts of garlic. It's believed to have some natural antifungal properties. (Fresh is considered best -- mince and put into empty gelatin capsules, up to 6 cloves a day.) (NOTE: It is unknown if large amounts of garlic interfere with HIV drugs, but some evidence exists that it may increase the risk of side effects from Norvir [ritonavir].)
  • Drink milk or eat yogurt with acidophilus bacteria: is "friendly" bacteria that helps keep your body in balance.

Treating and Preventing Fungal Infections Naturally

Nutritional approaches to prevent and treat conditions like candidiasis are complicated and controversial. While there isn't a magic recipe that prevents or treats yeast infections in everyone, following some basic guidelines may lower the risk of yeast becoming a problem for you.

Sugar, yeast, dairy, wheat, caffeine, nicotine and alcohol promote the growth of yeast. Nutritionists recommend ingesting as little as possible of these foods and products to decrease the risk and/or severity of yeast infections. Eating larger amounts of some foods may suppress the growth of yeast, like garlic or milk and yogurt that contain acidophilus.

Treating Vaginal Candidiasis
Topical Therapies
butoconazole 2% cream5 grams for 3 daysOver the counter; may weaken latex condoms/diaphragms
clotrimazole (Lotrimin) 1% cream5 grams for 7-14 daysOver the counter; may weaken latex condoms/diaphragms
clotrimazole (Mycelex) 100mg vaginal tabletOne 100mg tablet for 7 days or two 100mg tablets for 3 days 
clotrimazole (Mycelex) 500mg vaginal tabletSingle dose 
miconazole (Monistat) 2% cream5 grams for 7 daysOver the counter; may weaken latex condoms/diaphragms
miconazole (Monistat) 100mg suppositoryOnce a day for 7 daysOver the counter
miconazole (Monistat) 200mg suppositoryOnce a day for 3 daysOver the counter
miconazole (Monistat) 1,200mg suppositorySingle dose 
terconazole (Terazol 7) 0.4% cream5 grams for 7 daysMay weaken latex condoms/diaphragms
terconazole (Terazol 3) 0.8% cream5 grams for 3 daysMay weaken latex condoms/diaphragms
terconazole (Terazol 3) 80mg suppositoryOnce a day for 3 days 
tioconazole (Vagistat) 300mg ointmentSingle doseOver the counter
Oral Therapies
fluconazole (Diflucan)One 150mg doseNot recommended for pregnant women; sometimes used weekly as a prevention
itraconazole (Sporanox)One 100mg doseNot recommended for pregnant women; sometimes used weekly as a prevention
ketaconazole (Nizoral)One 200-400mg doseNot recommended for pregnant women; sometimes used weekly as a prevention
Other Therapies
nystatin vaginal tablet (Mycostatin)Applied to affected areas twice a day for 3 daysOver-the-counter. May be useful for recurrent (every 7 days for 1 month); messy; can cause vaginal swelling; refrain from sex
gentian violetApplied to affected areas once a week for 4 weeksAvailable over-the-counter; consult doctor for proper application

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